Consumer Complaint Form
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3State of Utah
Department of Financial Institutions
UTAH
CONSUMER COMPLAINT FORM
Please fill in this form completely, including your signature at the end of the form. The Department of
Financial Institutions (DFI) will only act on complaints that are signed by the complainant(s), legal
guardian, attorney of complainant(s) along with their client’s authorization, or holder of power of attor-
ney. DFI’s jurisdiction extends to Utah chartered depository institutions, consumer lenders, mortgage
servicers, limited mortgage lenders, Utah payday lenders, and Utah title loan lenders. If your complaint
relates to an entity not under our jurisdiction, we will forward your complaint on to the appropriate
regulator and notify you of that referral.
Include copies of documents related to your complaint such as contracts, monthly statements, receipts
and correspondence with the institution.
Mail or fax this completed complaint form with any attachments to:
Utah Department of Financial Institutions
PO Box 146800
Salt Lake City, UT 84114-6800
FAX (801) 538-8894
Complaint Type:
Depository
Consumer Lender
Mortgage Company
Payday or Title Lender
In filling out this form, print or type clearly so the information can be easily read and understood.
Customer Information:
Mr.
Ms.
Mrs.
Miss
Name:
First
Middle
Last
Address:
Street
City
State
Zip
Daytime Phone:
(
)
-
Ext:
Fax:
(
)
-
Email:
State of Utah
Department of Financial Institutions
Page 1 of 3
(v2/07)
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